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Correction to: Acute respiratory failure and the kinetics of neutrophil recovery in pediatric hematopoietic cell transplantation: a multicenter study. Bone Marrow Transplant 2019; 55:476. [PMID: 31822810 PMCID: PMC7608367 DOI: 10.1038/s41409-019-0767-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
An amendment to this paper has been published and can be accessed via a link at the top of the paper.
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Brachial plexitis: an unusual presentation in sickle cell disease. J Community Hosp Intern Med Perspect 2019; 9:437-439. [PMID: 31723392 PMCID: PMC6830239 DOI: 10.1080/20009666.2019.1659665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 08/20/2019] [Indexed: 10/28/2022] Open
Abstract
Brachial plexitis is defined as an inflammation of the brachial plexus. There are two entities of the disease: idiopathic, which is generally considered to be immune-mediated, and genetic. The disease manifests as the acute onset shoulder pain, weakness of the involving arm ± sensory loss. Brachial plexitis is also known as Parsonage-Turner syndrome and hereditary neuralgic amyotrophy. Diagnosis is made with the help of history, physical exam, and imaging. Conservative management is the mainstay of treatment. There has not been any proven treatment for the condition though some cases have been treated empirically with steroids. We present a case of 61-year-old woman with sickle cell anemia who presented with right upper extremity weakness and MRI findings of brachial plexitis.
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Acute respiratory failure and the kinetics of neutrophil recovery in pediatric hematopoietic cell transplantation: a multicenter study. Bone Marrow Transplant 2019; 55:341-348. [PMID: 31527817 PMCID: PMC7091821 DOI: 10.1038/s41409-019-0649-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 07/09/2019] [Accepted: 08/10/2019] [Indexed: 11/23/2022]
Abstract
In this multicenter study, we investigated the kinetics of neutrophil recovery in relation to acuity and survival among 125 children undergoing allogeneic hematopoietic cell transplantation (allo-HCT) who required invasive mechanical ventilation (IMV). Recovery of neutrophils, whether prior to or after initiation of IMV, was associated with a significantly decreased risk of death relative to never achieving neutrophil recovery. A transient increase in acuity (by oxygenation index and vasopressor requirements) occurred among a subset of the patients who achieved neutrophil recovery after initiation of IMV; 61.5% of these patients survived to discharge from the intensive care unit (ICU). Improved survival among patients who subsequently achieved neutrophil recovery on IMV was not limited to those with peri-engraftment respiratory distress syndrome. The presence of a respiratory pathogen did not affect the risk of death while on IMV but was associated with an increased length of IMV (p < 0.01). Among patients undergoing HCT who develop respiratory failure and require advanced therapeutic support, neutrophil recovery at time of IMV and/or presence of a respiratory pathogen should not be used as determining factors when counseling families about survival.
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Abstract
OBJECTIVE The presentation of cognitive impairments in HIV-infected individuals has transformed since the introduction of antiretroviral therapies. Although the overall prevalence of cognitive impairments has not changed considerably, frank dementia is now infrequent, and milder forms of cognitive impairments predominate. Mechanistic insights to the underlying causes of these residual cognitive impairments have been elusive, in part due to the heterogenous etiology of cognitive dysfunction in this population. Here, we sought to categorize longitudinal change in HIV-infected patients based on the performance in specific cognitive domains. DESIGN This study consisted of 193 participants from the CHARTER cohort with detailed demographic, clinical, and neuropsychological testing data obtained from 2 study visits interspersed by ∼6 months. Cognitive testing assessed executive function, learning and delayed recall, working memory, verbal fluency, speed of information processing, and motor skills. Change scores were calculated for each domain between the 2 study visits. Dimension reduction and clustering was accomplished by principal component analysis of change scores and k-means clustering to identify cognitive domains that group together and groups of subjects with similar patterns of change. RESULTS We identified 4 distinct cognitive change phenotypes that included declines in: (1) verbal fluency, (2) executive function (3) learning and recall, and (4) motor function, with approximately equal numbers of participants in each phenotype. CONCLUSIONS Each of the 4 cognitive change phenotypes identify deficits that imply perturbations in specific neural networks. Future studies will need to validate if cognitive change phenotypes are associated with alterations in associated neural pathways.
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Abstract
Abstract:Advances in electronic image recording and computer technologyhave resulted in a remarkable increase in the power and flexibility of interactive computer-video teaching systems. The University of Washington Health Science Videodisc Development Group first demonstrated a laser videodisc controlled by a remote central computer in 1980. Even this rudimentary unit highlighted basic medical informatics principles including: rapid accessibility; a “generic” or multi-purposed format; ease of computer control; and large collections of valid, rigorously reviewed images. Advances in medical informatics have led to the development of the following previously undescribed series of teaching units:1. The hypertext programs Hypercard, Linkway, and Guide have been used with videodiscs to develop easy-to-use instructional and reference materials. These materials demonstrate the ease with which a computer-naive instructor may develop new programs and the advantage that the intuitive nature of these programs brings to student users.2. Patient simulations using single and double screens plus pre-defined knowledge structures;3. Interactive single topic tutorials using preset knowledge structures;4. A key-word-based disc searching system;5. Electronic video microscopy;6. A series of programs developed independently by health science faculty who have purchased multi-purpose videodiscs that demonstrate the flexibility of the multi-purpose or “generic”: collection concept.
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Advanced Pediatric Neurosonography Techniques: Contrast-Enhanced Ultrasonography, Elastography, and Beyond. J Neuroimaging 2017; 28:150-157. [PMID: 29280236 DOI: 10.1111/jon.12492] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Revised: 11/12/2017] [Accepted: 11/15/2017] [Indexed: 12/29/2022] Open
Abstract
Recent technical advances in neurosonography continue broadening the diagnostic utility, sensitivity, and specificity of ultrasound for detecting intracranial abnormalities bed side. The clinical and functional applications of neurosonography have significantly expanded since the 1980s when transcranial Doppler sonography first allowed anatomic and hemodynamic delineation of the intracranial vessels through the thin temporal skull. In the past few years, contrast-enhanced ultrasonography, elastography, 3D/4D reconstruction tools, and high-resolution microvessel imaging techniques have further enhanced the diagnostic significance of neurosonography. Given these advances, a thorough familiarity with these new techniques and devices is crucial for a successful clinical application allowing improved patient care. It is essential that future neurosonography studies compare these advanced techniques against the current "gold standard" computed tomography and magnetic resonance imaging to assure the accuracy of their diagnostic potential. This review will provide a comprehensive update on currently available advanced neurosonography techniques.
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The use of an anterior pelvic internal fixator to treat disruptions of the anterior pelvic ring: a report of technique, indications and complications. Bone Joint J 2017; 99-B:1232-1236. [PMID: 28860405 DOI: 10.1302/0301-620x.99b9.bjj-2016-1025.r2] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 04/02/2017] [Indexed: 11/05/2022]
Abstract
AIMS The anterior pelvic internal fixator is increasingly used for the treatment of unstable, or displaced, injuries of the anterior pelvic ring. The evidence for its use, however, is limited. The aim of this paper is to describe the indications for its use, how it is applied and its complications. PATIENTS AND METHODS We reviewed the case notes and radiographs of 50 patients treated with an anterior pelvic internal fixator between April 2010 and December 2015 at a major trauma centre in the United Kingdom. The median follow-up time was 38 months (interquartile range 24 to 51). RESULTS Three patients were excluded from the analysis leaving 47 patients with complete follow-up data. Of the 47 patients, 46 achieved radiological union and one progressed to an asymptomatic nonunion. Of the remaining patients, 45 required supplementary posterior fixation with percutaneous iliosacral screws, 2 of which required sacral plating. The incidence of injury to the lateral femoral cutaneous nerve (LFCN) was 34%. The rate of infection was 2%. There were no other significant complications. Without this treatment, 44 patients (94%) would have needed unilateral or bilateral open reduction and plate fixation extending laterally to the hip joint. CONCLUSION The anterior pelvic internal fixator reduces the need for extensive open surgery and is a useful addition to the armamentarium for the treatment of anterior pelvic injuries. It is associated with injury to the LFCN in a third of patients. Cite this article: Bone Joint J 2017;99-B.1232-6.
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Cerebrospinal fluid cell-free mitochondrial DNA is associated with HIV replication, iron transport, and mild HIV-associated neurocognitive impairment. J Neuroinflammation 2017; 14:72. [PMID: 28359324 PMCID: PMC5374652 DOI: 10.1186/s12974-017-0848-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 03/21/2017] [Indexed: 12/19/2022] Open
Abstract
Background Mitochondria are abundant organelles critical for energy metabolism and brain function. Mitochondrial DNA (mtDNA), released during cellular injury and as part of the innate immune response to viral pathogens, contains CpG motifs that act as TLR-9 ligands. We investigated relationships between cerebrospinal fluid (CSF) cell-free mtDNA levels and HIV viral load (VL), biomarkers of inflammation and iron transport, and neurocognitive (NC) function in the CNS HIV Antiretroviral Therapy Effects Research (CHARTER) cohort. Methods We quantified cell-free mtDNA in CSF by droplet digital PCR in 332 CHARTER participants who underwent comprehensive neuropsychiatric evaluation. NC performance was assessed using the global deficit score (GDS) as either a continuous or a binary measure (GDS ≥ 0.5, impaired vs. GDS < 0.5, unimpaired). CSF, clinical, and biomarker data from the earliest available time point were analyzed. Cell-free mtDNA associations with CSF inflammation and iron-related biomarkers [CXCL10, IL-6, IL-8, TNF-a, transferrin (TF), ceruloplasmin (CP), and vascular endothelial growth factor (VEGF)], VL, and GDS were evaluated by multivariable regression. Results CSF cell-free mtDNA levels were significantly lower in participants with undetectable (vs. detectable) VL in either plasma (p < 0.001) or CSF (p < 0.001) and in those on antiretroviral therapy (ART; p < 0.001). Participants on ART with undetectable VL in both CSF and plasma had lower mtDNA levels than those with detectable VL in both compartments (p = 0.001). Higher mtDNA levels were observed in participants in the highest vs. lowest tertile (T3 vs. T1) of CSF CXCL10 (T3 vs. T1, p < 0.001) and TNF-a (T3 vs. T1, p < 0.05) in unadjusted analyses. MtDNA levels also correlated with CSF leukocyte count. After adjusting for CSF leukocyte count and VL, mtDNA levels were also associated with other inflammation- and iron-related biomarkers in CSF, including TF (T3 vs. T1, p < 0.05) and CP (T3 vs. T1, p < 0.05). With additional correction for ART use, mtDNA was also negatively associated with CSF VEGF (p < 0.05) and IL-6 (p = 0.05). We observed no associations of CSF mtDNA levels with age or GDS-defined NC impairment. Conclusions CSF cell-free mtDNA levels were associated with HIV RNA and ART status, as well as with biomarkers of iron transport and VEGF, a growth factor with known effects on mitochondrial integrity and autophagy. CSF mtDNA may be a biomarker of iron dysregulation and/or neuroinflammation during HIV infection. Electronic supplementary material The online version of this article (doi:10.1186/s12974-017-0848-z) contains supplementary material, which is available to authorized users.
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The Warwick Hip Trauma Evaluation One: a randomised pilot trial comparing the X-Bolt Dynamic Hip Plating System with sliding hip screw fixation in complex extracapsular hip fractures: WHiTE (One). Bone Joint J 2017; 98-B:686-9. [PMID: 27143742 DOI: 10.1302/0301-620x.98b5.37350] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 01/13/2016] [Indexed: 11/05/2022]
Abstract
AIMS The aim of this study was to inform a definitive trial which could determine the clinical effectiveness of the X-Bolt Dynamic Hip Plating System compared with the sliding hip screw for patients with complex pertrochanteric fragility fractures of the femur. PATIENTS AND METHODS This was a single centre, participant blinded, randomised, standard-of-care controlled pilot trial. Patients aged 60 years and over with AO/ASIF A2 and A3 type femoral pertrochanteric fractures were eligible. RESULTS The primary outcome was the EuroQoL 5 Dimension Score (EQ-5D-3L) at one year following index fixation. A total of 100 participants were recruited, and primary outcome data were available for 88 patients following losses to follow-up and withdrawals. The mean difference in EQ-5D was 0.03 (95% confidence interval -0.17, 0.120; p = 0.720.) There were no significant differences in any of the secondary outcomes measures. The recruitment and follow-up rates from this feasibility study were as predicted. CONCLUSION A definitive trial with 90% power to find a clinically important difference in EQ-5D would require 964 participants based upon the data from this study. We plan to start recruitment to this trial in Spring 2016. TAKE HOME MESSAGE A definitive trial of X-Bolt Dynamic Hip Plating System is feasible and should be conducted now in order to quantify the clinical effectiveness of this novel implant. Cite this article: Bone Joint J 2016;98-B:686-9.
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A Comparison of Five Brief Screening Tools for HIV-Associated Neurocognitive Disorders in the USA and South Africa. AIDS Behav 2016; 20:1621-31. [PMID: 26860536 DOI: 10.1007/s10461-016-1316-y] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Screening for HIV-associated neurocognitive disorders (HAND) is important to improve clinical outcomes. We compared the diagnostic sensitivity and specificity of the mini-mental state examination, International HIV dementia scale (IHDS), Montreal cognitive assessment, Simioni symptom questionnaire and cognitive assessment tool-rapid version (CAT-rapid) to a gold standard neuropsychological battery. Antiretroviral-experienced participants from Cape Town, South Africa, and Baltimore, USA, were recruited. The sensitivity and specificity of the five tools, as well as those of the combined IHDS and CAT-rapid, were established using 2 × 2 contingency tables and ROC analysis. More than a third (65165) had symptomatic HAND. In detecting HIV-D, the CAT-Rapid had good sensitivity (94 %) and weak specificity (52 %) (cut-point ≤10), while the IHDS showed fair sensitivity (68 %) and good specificity (86 %) (cut-point ≤10). The combined IHDS and CAT-rapid showed excellent sensitivity and specificity for HIV-D at a cut-off score of ≤16 (out of 20; 89 and 82 %). No tool was adequate in screening for any HAND. The combination IHDS and CAT-rapid tool appears to be a good screener for HIV-D but is only fairly sensitive and poorly specific in screening for any HAND. Screening for milder forms of HAND continues to be a clinical challenge.
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Treatment of human immunodeficiency virus-related peripheral neuropathy with Scrambler Therapy: a case report. Int J STD AIDS 2016; 28:202-204. [PMID: 27330020 DOI: 10.1177/0956462416656688] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Peripheral neuropathy is one of the most common neurological complications of HIV infection with a 30-60% lifetime prevalence. Newer HIV drugs cause less peripheral neuropathy, but patients are now living long enough to develop concomitant diabetes-related, vascular-related, and chemotherapy-related neuropathy so it continues as a major debilitating issue. Recent national CDC guidelines have stressed the importance of non-opioid therapies, especially in this population that may have had drug abuse problems. We treated a 52-year-old man who had severe disabling classic peripheral neuropathy since 1998 with Scrambler Therapy (Calmare), an FDA-cleared peripheral non-invasive neuromodulation device. His pain rapidly improved, as did his motor and sensory function, with just four 45-min treatments, and he was able to come off opioids for the first time in years. When his pain returned six months later, only two treatments were needed to resolve it. This represents the first published use of this novel, inexpensive, and non-invasive pain modality in HIV peripheral neuropathy, and should engender further trials.
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MITOCHONDRIAL MUTATIONS IN HIV-ASSOCIATED SENSORY NEUROPATHY. Journal of Neurology, Neurosurgery and Psychiatry 2014. [DOI: 10.1136/jnnp-2014-309236.26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Abstract
Emerging infections affecting the central nervous system often present as encephalitis and can cause substantial morbidity and mortality. Diagnosis requires not only careful history taking, but also the application of newly developed diagnostic tests. These diseases frequently occur in outbreaks stemming from viruses that have mutated from an animal host and gained the ability to infect humans. With globalization, this can translate to the rapid emergence of infectious clusters or the establishment of endemicity in previously naïve locations. Since these infections are often vector borne and effective treatments are almost uniformly lacking, prevention is at least as important as prompt diagnosis and institution of supportive care. In this review, we focus on some of the recent literature addressing emerging and resurging viral encephalitides in the United States and around the world-specifically, West Nile virus, dengue, polio, and cycloviruses. We also discuss new, or "emerging," techniques for the precise and rapid diagnosis of encephalitides.
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Anterior spinal artery syndrome presenting as cervical myelopathy in a patient with subclavian steal syndrome. Neurol Clin Pract 2013; 3:358-360. [PMID: 24195022 DOI: 10.1212/cpj.0b013e318296f217] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The anterior spinal artery syndrome (ASAS), described by Preobraschenski in 1908,1 is characterized by bilateral spastic paraparesis and dissociated sensory deficits involving bilateral loss of temperature and pain sensation but preserved proprioception and touch. The ASAS typically develops acutely, over minutes to hours. While initially linked to infections, in particular syphilis, many other etiologies are now recognized, including aortic atheromatous disease and thromboembolic phenomenon. We report a case of ASAS in a patient with a steal phenomenon secondary to a right-sided aortic arch with interruption of the left subclavian artery (SCA).
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The Warwick Hip Trauma Evaluation One -an abridged protocol for the WHiTE One Study: An embedded randomised trial comparing the X-bolt with slidinghip screw fixation in extracapsular hip fractures. Bone Joint Res 2013; 2:206-9. [PMID: 24089290 PMCID: PMC3791484 DOI: 10.1302/2046-3758.210.2000183] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Accepted: 07/04/2013] [Indexed: 11/10/2022] Open
Abstract
Fractures of the proximal femur are one of the greatest challenges facing the medical community, constituting a heavy socioeconomic burden worldwide. Controversy exists regarding the optimal treatment for patients with unstable trochanteric proximal femoral fractures. The recognised treatment alternatives are extramedullary fixation usually with a sliding hip screw and intramedullary fixation with a cephalomedullary nail. Current evidence suggests that best results and lowest complication rates occur using a sliding hip screw. Complications in these difficult fractures are relatively common regardless of type of treatment. We believe that a novel device, the X-Bolt dynamic plating system, may offer superior fixation over a sliding hip screw with lower reoperation risk and better function. We therefore propose to investigate the clinical effectiveness of the X-bolt dynamic plating system compared with standard sliding hip screw fixation within the framework of a the larger WHiTE (Warwick Hip Trauma Evaluation) Comprehensive Cohort Study. Cite this article: Bone Joint Res 2013;2:206-9.
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The Warwick Hip Trauma Evaluation Two -an abridged protocol for the WHiTE Two Study: An embedded randomised trial comparing the Dual-Mobility withpolyethylene cups in hip arthroplasty for fracture. Bone Joint Res 2013; 2:210-3. [PMID: 24089291 PMCID: PMC3791483 DOI: 10.1302/2046-3758.210.2000186] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Fractures of the proximal femur are one of the
greatest challenges facing the medical community, constituting a
heavy socioeconomic burden worldwide. Controversy exists regarding
the optimal treatment for independent patients with displaced intracapsular fractures
of the proximal femur. The recognised alternatives are hemiarthroplasty
and total hip replacement. At present there is no established standard
of care, with both types of arthroplasty being used in many centres.
The principal advantages of total hip replacement are a functional
benefit over hemiarthroplasty and a reduced risk of revision surgery.
The principal criticism is the increased risk of dislocation. We
believe that an alternative acetabular component may reduce the
risk of dislocation but still provide the functional benefit of
total hip replacement in these patients. We therefore propose to
investigate the dislocation risk of a dual-mobility acetabular component
compared with standard polyethylene component in total hip replacement
for independent patients with displaced intracapsular fractures
of the proximal femur within the framework of the larger WHiTE (Warwick
Hip Trauma Evaluation) Comprehensive Cohort Study. Cite this article: Bone Joint Res 2013;2:210–13.
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Abstract
Cognitive impairment is common in HIV-infected individuals, as is syphilis. Treponema pallidum, the bacterium that causes syphilis, invades the central nervous system early in disease. We hypothesized that HIV-infected patients with a history of syphilis or neurosyphilis would have more cognitive impairment than HIV-infected individuals without these infections. Eighty-two of 1574 enrollees in CHARTER, a prospective, observational study, had reactive serum rapid plasma reagin (RPR) tests. They were matched to 84 controls with non-reactive RPR by age, gender, ethnicity and HIV risk factor. Participants underwent comprehensive neuropsychological (NP) evaluations. RPR results were confirmed and serum fluorescent treponemal antibody absorption (FTA-ABS) test reactivity determined at a central laboratory. Sera from 101 of 166 participants were FTA-ABS reactive, indicating past or current syphilis. Among the 136 individuals without confounding conditions, compared with patients who had never had syphilis, those with prior syphilis had a greater number of impaired NP test domains (1.90 SD [1.77] versus 1.25 [1.52], P = 0.03), a higher global deficit score (0.47 [0.46] versus 0.31 [0.33], P = 0.03), and more were impaired in the NP learning domain (36 [42.9%] of 84 versus 13 [25.0%] of 52, P = 0.04). These effects of prior syphilis remained after controlling for education and premorbid intelligence.
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Darunavir is predominantly unbound to protein in cerebrospinal fluid and concentrations exceed the wild-type HIV-1 median 90% inhibitory concentration. J Antimicrob Chemother 2013; 68:684-9. [PMID: 23143899 PMCID: PMC3566670 DOI: 10.1093/jac/dks441] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Revised: 10/03/2012] [Accepted: 10/10/2012] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Higher CSF antiretroviral concentrations may be associated with better control of HIV replication and neurocognitive performance, but only the unbound fraction of antiretrovirals is available to inhibit HIV. Therefore, the objective of this study was to determine total and unbound darunavir concentrations in CSF and compare findings with plasma concentrations as well as the wild-type HIV-1 90% inhibitory concentration (IC(90)). METHODS Subjects with HIV infection were selected based on the use of darunavir-containing regimens with a twice-daily dosing schedule and availability of stored CSF and matched plasma. Total darunavir was measured by HPLC for plasma or liquid chromatography-tandem mass spectroscopy (LC/MS/MS) for CSF. Plasma unbound darunavir was measured by ultrafiltration and LC/MS/MS. CSF protein binding was determined by competitive binding exchange with radiolabelled darunavir. RESULTS Twenty-nine matched CSF-plasma pairs were analysed and darunavir was detected in all CSF specimens (median total concentration 55.8 ng/mL), with a CSF unbound fraction of 93.5%. Median fractional penetrance was 1.4% of median total and 9.4% of median unbound plasma concentrations. Unbound darunavir concentrations in CSF exceeded the median IC(90) for wild-type HIV in all subjects by a median of 20.6-fold, despite the relatively low fractional penetrance. Total darunavir concentrations in CSF correlated with both total and unbound darunavir concentrations in plasma. CONCLUSIONS Darunavir should contribute to the control of HIV replication in the CNS as a component of effective combination antiretroviral regimens.
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Abstract
Neurologic complications for HIV-infected persons retain significant prevalence despite an increasingly global use of antiretroviral therapies. Such complications are often ascribed to advanced immunosuppression; however, the most common neurologic problems for HIV-infected persons, distal sensory polyneuropathy and HIV-associated neurocognitive disorders, affect a significant proportion of patients who have successfully achieved immunologic restoration with normal or near-normal CD4 count levels and undetectable HIV RNA in the periphery. Understanding specific considerations for HIV-associated complications, including the epidemiology, risk factors, medication-adverse effects, and benefits of appropriate management, is vital for all providers caring for those with HIV. This review will describe such considerations, as well as providing a more detailed review of the most common neurologic complications of HIV infection, and will highlight some of the challenges involved with diagnosis, management, and long-term effects.
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Abstract
OBJECTIVES Etravirine has high affinity for plasma drug-binding proteins, such as albumin and α1-acid glycoprotein, which limits the amount of unbound etravirine available to enter the CNS. The objective of this study was to compare total and unbound etravirine concentrations in CSF with plasma concentrations and the in vitro median inhibitory concentration (IC50) for wild-type HIV (0.9 ng/mL). METHODS Total and bound etravirine concentrations were measured in 17 CSF and plasma pairs by isotope-dilution liquid chromatography tandem mass spectroscopy, radioligand displacement and ultracentrifugation. Unbound etravirine concentrations were calculated from the bound fraction. The dynamic range of the assay was 7.8-2000 (plasma) and 0.78-200 (CSF) ng/mL. RESULTS Subjects were mostly middle-aged (median 43 years) white (78%) men (89%). All CSF etravirine concentrations were above the limit of quantification. Total and unbound median etravirine concentrations in CSF were 9.5 (IQR 6.4, 26.4) and 0.13 (IQR 0.08, 0.27) ng/mL, respectively. Etravirine was 96% (IQR 94.5, 97.2) protein bound in plasma and 98.4% (IQR 97.8, 98.8) in CSF. Total etravirine in CSF was 4.3% (IQR 3, 5.9) of total and 101% (IQR 76, 160) of unbound etravirine in plasma. There were no significant correlations between unbound etravirine concentrations and concentrations of albumin in plasma or CSF. Unbound etravirine concentrations in CSF did not reach the wild-type IC50 in any of the specimens. CONCLUSIONS Unbound etravirine may not achieve optimal concentrations to inhibit HIV replication in the CNS.
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Relationship of Medication Management Test-Revised (MMT-R) performance to neuropsychological functioning and antiretroviral adherence in adults with HIV. AIDS Behav 2012; 16:2286-96. [PMID: 22722882 DOI: 10.1007/s10461-012-0237-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
While performance-based tests of everyday functioning offer promise in facilitating diagnosis and classification of HIV-associated neurocognitive disorders (HAND), there remains a dearth of well-validated instruments. In the present study, clinical correlates of performance on one such measure (i.e., Medication Management Test-Revised; MMT-R) were examined in 448 HIV+ adults who were prescribed antiretroviral therapy. Significant bivariate relationships were found between MMT-R scores and demographics (e.g., education), hepatitis C co-infection, estimated premorbid IQ, neuropsychological functioning, and practical work abilities. MMT-R scores were not related to HIV disease severity, psychiatric factors, or self-reported adherence among participants with a broad range of current health status. However, lower MMT-R scores were strongly and uniquely associated with poorer adherence among participants with CD4 T cell counts <200. In multivariate analyses, MMT-R scores were predicted by practical work abilities, estimated premorbid functioning, attention/working memory, learning, and education. Findings provide overall mixed support for the construct validity of the MMT-R and are discussed in the context of their clinical and research implications for evaluation of HAND.
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A comparative evaluation of quantitative neuroimaging measurements of brain status in HIV infection. Psychiatry Res 2012; 203:95-9. [PMID: 22892348 PMCID: PMC3771520 DOI: 10.1016/j.pscychresns.2011.08.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2011] [Revised: 08/12/2011] [Accepted: 08/29/2011] [Indexed: 11/16/2022]
Abstract
Diffusion tensor imaging (DTI), magnetization transfer imaging (MT) and automated brain volumetry were used to summarize brain involvement in human immunodeficiency virus (HIV) infection. A multiparametric neuroimaging protocol was implemented at 1.5 T in 10 HIV+ and 24 controls. Various summary parameters were calculated based on DTI, MT, and automated brain volumetry. The magnitude of the difference, as well as the between-group discrimination, was determined for each measure. Bivariate correlations were computed and redundancy among imaging parameters was examined by principal factor analysis. Significant or nearly significant differences were found for most measures. Large Cohen's d effect sizes were indicated for mean diffusivity (MD), fractional anisotropy (FA), magnetization transfer ratio (MTR) and gray matter volume fraction (GM). Between-group discrimination was excellent for FA and MTR and acceptable for MD. Correlations among all imaging parameters could be explained by three factors, possibly reflecting general atrophy, neuronal loss, and alterations. This investigation supports the utility of summary measurements of brain involvement in HIV infection. The findings also support assumptions concerning the enhanced sensitivity of DTI and MT to atrophic as well as alterations in the brain. These findings are broadly generalizable to brain imaging studies of physiological and pathological processes.
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Mild Neurocognitive Impairment in HIV Infection Is Associated with Neuroinflammation on Positron Emission Tomography (S37.003). Neurology 2012. [DOI: 10.1212/wnl.78.1_meetingabstracts.s37.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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A Common Polymorphism in the COMT Gene Confers an Increased Risk of Neuropathic Pain in HIV Sensory Neuropathy (S37.006). Neurology 2012. [DOI: 10.1212/wnl.78.1_meetingabstracts.s37.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Mild Neurocognitive Impairment in HIV Infection Is Associated with Neuroinflammation on Positron Emission Tomography (IN3-1.008). Neurology 2012. [DOI: 10.1212/wnl.78.1_meetingabstracts.in3-1.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Attributable Burden of Neurological Disease in Older HIV-Positive Versus HIV-Negative Men: Findings from the Multicenter AIDS Cohort Study (MACS), 1997-2009 (P01.257). Neurology 2012. [DOI: 10.1212/wnl.78.1_meetingabstracts.p01.257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Abstract
BACKGROUND : To determine how serious a confound substance use (SU) might be in studies on HIV-associated neurocognitive disorder (HAND), we examined the relationship of SU history to neurocognitive impairment (NCI) in participants enrolled in the Central Nervous System HIV Antiretroviral Therapy Effects Research study. METHODS : After excluding cases with behavioral evidence of acute intoxication and histories of factors that independently could account for NCI (eg, stroke), baseline demographic, medical, SU, and neurocognitive data were analyzed from 399 participants. Potential SU risk for NCI was determined by the following criteria: lifetime SU Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnosis, self-report of marked lifetime SU, or positive urine toxicology. Participants were divided into 3 groups as follows: no SU (n = 134), nonsyndromic SU (n = 131), syndromic SU (n = 134) and matched on literacy level, nadir CD4, and depressive symptoms. RESULTS : Although approximately 50% of the participants were diagnosed with HAND, a multivariate analysis of covariance of neurocogntive summary scores, covarying for urine toxicology, revealed no significant effect of SU status. Correlational analyses indicated weak associations between lifetime heroin dosage and poor recall and working memory and between cannabis and cocaine use and better verbal fluency. CONCLUSIONS : These data indicate that HIV neurocognitive effects are seen at about the same frequency in those with and without historic substance abuse in cases that are equated on other factors that might contribute to NCI. Therefore, studies on neuroAIDS and its treatment need not exclude such cases. However, the effects of acute SU and current SU disorders on HAND require further study.
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Clinical variables identify seronegative HCV co-infection in HIV-infected individuals. J Clin Virol 2011; 52:328-32. [PMID: 21924674 DOI: 10.1016/j.jcv.2011.08.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2011] [Revised: 08/18/2011] [Accepted: 08/20/2011] [Indexed: 12/24/2022]
Abstract
BACKGROUND A substantial number of people living with HIV (PLWH) are co-infected with Hepatitis C Virus (HCV) but have a negative screening HCV antibody test (seronegative HCV infection, or SN-HCV). OBJECTIVE To identify a concise set of clinical variables that could be used to improve case finding for SN-HCV co-infection among PLWH. STUDY DESIGN Two hundred HIV-infected participants of the CHARTER study were selected based on 7 clinical variables associated with HCV infection but were HCV seronegative. Data were analyzed using Fisher's exact tests, receiver-operating characteristic (ROC) curves, and logistic regression. RESULTS Twenty-six (13%) participants had detectable HCV RNA. SN-HCV was associated with a history of IDU, elevated ALT and AST, low platelets, black ethnicity, and undetectable HIV RNA in plasma. Each of these clinical variables, except for abnormal AST, remained independently associated with SN-HCV in a multivariate logistic regression analysis. A composite risk score correctly identified SN-HCV with sensitivity up to 85% and specificity up to 88%. CONCLUSIONS In a substantial minority of PLWH, seronegative HCV viremia can be predicted by a small number of clinical variables. These findings, after validation in an unselected cohort, could help focus screening in those at highest risk.
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Normative data and validation of a regression based summary score for assessing meaningful neuropsychological change. J Clin Exp Neuropsychol 2011; 33:505-22. [PMID: 21391011 DOI: 10.1080/13803395.2010.535504] [Citation(s) in RCA: 133] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Reliable detection and quantification of longitudinal cognitive change are of considerable importance in many neurological disorders, particularly to monitor central nervous system effects of disease progression and treatment. In the current study, we developed normative data for repeated neuropsychological (NP) assessments (6 testings) using a modified standard regression-based (SRB) approach in a sample that includes both HIV-uninfected (HIV-, N = 172) and neuromedically stable HIV-infected (HIV+, N = 124) individuals. Prior analyses indicated no differences in NP change between the infected and uninfected participants. The norms for change included correction for factors found to significantly affect follow-up performance, using hierarchical regression. The most robust and consistent predictors of follow-up performance were the prior performance on the same test (which contributed in all models) and a measure of prior overall NP competence (predictor in 97% of all models). Demographic variables were predictors in 10-46% of all models and in small amounts; while test-retest interval contributed in only 6% of all models. Based on the regression equations, standardized change scores (z scores) were computed for each test measure at each interval; these z scores were then averaged to create a total battery change score. An independent sample of HIV- participants who had completed 8 of the 15 tests was used to validate an abridged summary change score. The normative data are available in an electronic format by e-mail request to the first author. Correction for practice effects based on normative data improved the consistency of NP impairment classification in a clinically stable longitudinal cohort after baseline.
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Effects of traumatic brain injury on cognitive functioning and cerebral metabolites in HIV-infected individuals. J Clin Exp Neuropsychol 2011; 33:326-34. [PMID: 21229435 PMCID: PMC3062232 DOI: 10.1080/13803395.2010.518140] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
We explored the possible augmenting effect of traumatic brain injury (TBI) history on HIV (human immunodeficiency virus) associated neurocognitive complications. HIV-infected participants with self-reported history of definite TBI were compared to HIV patients without TBI history. Groups were equated for relevant demographic and HIV-associated characteristics. The TBI group evidenced significantly greater deficits in executive functioning and working memory. N-acetylaspartate, a putative marker of neuronal integrity, was significantly lower in the frontal gray matter and basal ganglia brain regions of the TBI group. Together, these results suggest an additional brain impact of TBI over that from HIV alone. One clinical implication is that HIV patients with TBI history may need to be monitored more closely for increased risk of HIV-associated neurocognitive disorder signs or symptoms.
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Family history of dementia predicts worse neuropsychological functioning among HIV-infected persons. J Neuropsychiatry Clin Neurosci 2011; 23:316-23. [PMID: 21948893 PMCID: PMC3279193 DOI: 10.1176/jnp.23.3.jnp316] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
HIV-negative individuals with a family history of dementia (FHD) are more likely to develop dementia than those without FHD. Whether FHD increases risk for neuropsychological (NP) impairment in HIV+ persons is unknown. As part of a multisite study into HIV-associated neurocognitive disorders (HAND), the authors captured FHD with a free-response, self-report question, and assessed NP performance with a comprehensive battery of tests. The authors examined HIV+ persons with (N=190) and without (N=916) self-reported FHD. Despite the fact that the FHD group had factors typically associated with better NP performance (e.g., higher CD4 counts and estimated verbal IQ), persons with FHD had significantly worse NP ability than those without FHD as measured by a Global Deficit Score. Thus, FHD appears to be a risk factor for HAND; the mechanism(s) underlying how FHD contributes to NP impairment among HIV+ persons warrants study.
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Comparison of scales to evaluate the progression of HIV-associated neurocognitive disorder. ACTA ACUST UNITED AC 2010; 4:371-379. [PMID: 20824119 DOI: 10.2217/hiv.10.23] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
AIM: First, to compare the characterization of neurocognitive deficits in milder stages of HIV-associated neurocognitive disorder (HAND) derived from existing dementia rating scales of the American Academy of Neurology (AAN) and Memorial Sloan Kettering (MSK) with the 2007 consensus ('Frascati') classification. Second, to identify potential sociodemographic and clinical predictors of HAND progression during 1-year follow-up. METHODS: 104 HIV-infected subjects in an existing cohort system were evaluated with a medical history, exam, neuropsychological test battery and functional assessments. The degree of HAND was rated using the AAN, MSK and Frascati scales. The degree of concordance among these scales was determined. In addition, 45 subjects were reassessed for changes in their neurocognitive status at 1-year follow-up. Associations between age, education, sex, depression ratings, substance abuse, race, hepatitis C serostatus, CD4 count and progression of HAND were examined. RESULTS: There was excellent concordance (gamma > 0.8) among the Frascati, MSK and AAN ratings. Subjects rated as having minor cognitive motor disorder on the AAN scale (n = 45) were evenly split between Frascati rating of asymptomatic neurocognitive impairment (n = 24) and mild neurocognitive disorder (n = 21). At 1-year follow-up of 45 subjects, 31% had worsened, 13% had improved and 56% were stable. Predictors of progression included age older than 50 years (odds ratio: 5.57; p = 0.013) and female gender (odds ratio: 3.13; p = 0.036). CONCLUSION: The Frascati HAND rating scale has excellent concordance with previous neurocognitive rating scales and can be used to better characterize milder stages of cognitive impairment. Older individuals and women appeared to be more likely to show neurocognitive progression.
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The care of critically ill children after hematopoietic SCT: a North American survey. Bone Marrow Transplant 2010; 46:227-31. [PMID: 20400981 DOI: 10.1038/bmt.2010.89] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Although potentially curative, hematopoietic SCT (HSCT) is associated with significant morbidity. To improve outcomes, multicenter studies of critical illness in this patient population appear needed. To assist in the design of such studies, a survey was conducted to identify variations in care provided to critically ill pediatric HSCT patients. A survey was conducted of the highest volume pediatric HSCT centers in the United States (n=30) and Canada (n=4). One pediatric critical care medicine (PCCM) physician and one pediatric HSCT physician were surveyed at each institution. Analysis consisted of descriptive statistics. Thirty-three (29 United States/4 Canada) of 34 institutions responded. Although most HSCT units permit fluid boluses and nearly half permit some dose of dopamine, high-dose dopamine and other vasoactive infusions are rarely allowed there. Six institutions (21%) permit non-invasive ventilation on the HSCT unit. Criterion for PCCM consultation and therapies implemented before intubation vary significantly. High-frequency oscillatory ventilation and renal replacement therapy are commonly used for lung injury in patients failing conventional therapy. Variability exists in the location and type of therapy critically ill pediatric HSCT patients receive. Understanding this variability will help facilitate the design of clinical trials.
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Abstract
Abstract
Background
HIV-associated neurocognitive disorders (HAND) has been associated with the up-regulation of various oxidative stress pathways. Previous studies have linked the neuronal damage observed in individuals diagnosed with HAND to increased nitrotyrosine modification of neuronal proteins.
Materials and methods
Tyrosine nitration alters protein structure and function, affects biological half-life, and potentially prevents the phosphorylation of key tyrosine residues involved in signal transduction pathways. Therefore, in this study we employed proteomics-based experimental approaches to investigate nitrotyrosine-modified proteins in pooled cerebrospinal fluid (CSF) of individuals diagnosed with HAND. To identify specific nitrotyrosine-modified proteins in the CSF of individuals diagnosed with HAND, affinity purification and high-performance tandem mass spectrometry are utilized in a “bottom-up” proteomics approach.
Results
From tandem mass spectrometric analysis, we identified major proteins that underwent nitration as a result of nitro-oxidative stress in the CSF of individuals diagnosed with HAND. We also utilized analytical and biochemical techniques to characterize the expression and modification site of in vivo nitrated lipocalin-type prostaglandin-D synthase in HAND CSF.
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Clinical Outcomes Of Pediatric Patients Requiring Intensive Cardiopulmonary Support During HSCT. Biol Blood Marrow Transplant 2010. [DOI: 10.1016/j.bbmt.2009.12.263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Biomarkers of neurological status in HIV infection: a 3-year study. Proteomics Clin Appl 2010; 4:295-303. [PMID: 21137050 DOI: 10.1002/prca.200900083] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2009] [Revised: 07/24/2009] [Accepted: 10/08/2009] [Indexed: 01/12/2023]
Abstract
PURPOSE To evaluate circulating cytokines and chemokines as correlates of the degree of brain injury in individuals with advanced human immunodeficiency virus (HIV) infection. EXPERIMENTAL DESIGN Study participants included ten well-characterized subjects in advanced stage HIV infection. High-throughput multiplexed analysis was used to quantify markers of interest at baseline and 3 years later in the clinical course. Objective measurements of the brain were derived in vivo with quantitative magnetic resonance segmentation algorithms and with diffusion tensor imaging. RESULTS Of the markers examined, monocyte chemoattractant protein-1 (MCP-1 or CCL-2) was the most prominent correlate of brain injury. Elevated MCP-1 levels correlated with brain white matter alterations at the initial assessment. The relationship to injury was more extensive 3 years later; elevated MCP-1 was significantly correlated with measures of brain microstructural alterations and of abject atrophy. CONCLUSIONS AND CLINICAL RELEVANCE The findings build on our prior observations that elevated MCP-1 levels may be a useful predictive marker for HIV-associated neurocognitive disorder. As a potent chemoattractant, MCP-1 may mediate injury through participation in self-reinforcing cycles of chronic immune activation and cytokine/chemokine-mediated neurotoxicity.
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PML-IRIS in patients with HIV infection: clinical manifestations and treatment with steroids. Neurology 2009; 72:1458-64. [PMID: 19129505 DOI: 10.1212/01.wnl.0000343510.08643.74] [Citation(s) in RCA: 247] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Progressive multifocal leukoencephalopathy (PML) is an opportunistic infection that develops in immunosuppressed patients with HIV infection. Paradoxically, some of these patients may develop PML during combined antiretroviral therapy in the setting of immune reconstitution. We describe the types of PML in relation to immune reconstitution inflammatory syndrome (IRIS) and the effects of steroid use in these patients. METHODS We performed a retrospective review of the literature (1998 to 2007) and of all HIV-infected patients diagnosed with PML-IRIS at Johns Hopkins Hospital (2004 to 2007). We recorded information on clinical features, microbiologic and virological analysis, neuroimaging, pathology, treatment, and outcome. RESULTS Of 54 patients with PML-IRIS, 36 developed PML and IRIS simultaneously (PML-s-IRIS) and 18 had worsening of preexisting PML (PML-d-IRIS) after the initiation of combined antiretroviral therapy. PML-IRIS developed between 1 week and 26 months after initiation of antiretroviral therapy. PML-d-IRIS patients developed IRIS earlier, had higher lesion loads on MRI of the brain, had shorter durations of survival, and had higher mortality rate compared to PML-s-IRIS patients. Twelve patients received treatment with steroids, of which five died and seven showed good neurologic recovery. Patients who survived had received steroids early after IRIS diagnosis for longer durations and had contrast enhancement on IRIS neuroimaging. CONCLUSIONS Immune reconstitution following initiation of combined antiretroviral therapy may lead to activation of an inflammatory response to detectable or latent JC virus infection. Early and prolonged treatment with steroids may be useful in these patients but requires further investigation.
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The implications of low-speed fixed-wing aerofoil measurements on the analysis and performance of flapping bird wings. ACTA ACUST UNITED AC 2008; 211:215-23. [PMID: 18165249 DOI: 10.1242/jeb.007823] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Bird flight occurs over a range of Reynolds numbers (Re; 10(4) < or = Re < or = 10(5), where Re is a measure of the relative importance of inertia and viscosity) that includes regimes where standard aerofoil performance is difficult to predict, compute or measure, with large performance jumps in response to small changes in geometry or environmental conditions. A comparison of measurements of fixed wing performance as a function of Re, combined with quantitative flow visualisation techniques, shows that, surprisingly, wakes of flapping bird wings at moderate flight speeds admit to certain simplifications where their basic properties can be understood through quasi-steady analysis. Indeed, a commonly cited measure of the relative flapping frequency, or wake unsteadiness, the Strouhal number, is seen to be approximately constant in accordance with a simple requirement for maintaining a moderate local angle of attack on the wing. Together, the measurements imply a fine control of boundary layer separation on the wings, with implications for control strategies and wing shape selection by natural and artificial fliers.
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Abstract
Dementia remains one of the most fearsome complications of HIV infection. It also poses a significant challenge for the clinician both in terms of diagnosis and treatment. The use of antiretroviral agents has led to a decrease in the incidence of HIV dementia but the prevalence of milder forms of neurocognitive impairment has increased. Occasionally, the immune reconstitution caused by these agents may target the brain leading to a syndrome characterized by a severe, progressive and often fatal dementia. The progression of HIV dementia may also be determined by host and viral genetic factors, and the existence of co-morbid factors such as drug abuse, hepatitis C infection and aging. Oxidative stress markers appear to be predictive of active dementia. However, currently there is no specific treatment available for HIV dementia.
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Abstract
BACKGROUND The prevalence of HIV-associated neurocognitive disorders is increasing as HIV-infected individuals are living longer. The clinical manifestations of the syndrome also continue to evolve under the influence of antiretroviral drugs and comorbidities such as drugs of abuse. However, there are no surrogate markers for the disease, either to identify it de novo or to track its progression, and there is no proven treatment with the exception of antiretroviral drugs. METHODS Levels of nitric oxide, nitrate, and 3-nitrotyrosine (3-NT)-modified proteins were measured in the CSF of 46 patients with HIV infection stratified according to their neurocognitive status and history of IV drug use (IVD). The 3-NT-modified proteins were isolated and identified by tandem mass spectrometry, and the functional consequence of 3-NT modification of L-prostaglandin D synthase (L-PGDS), the most abundant protein, was determined. RESULTS 3-NT-modified proteins were significantly elevated in patients with HIV infection who had progressive neurocognitive decline over the next 6 months and in patients with a history of IVD. Thirteen different proteins with 3-NT modification were identified in the CSF of these patients. L-PGDS was the most abundant. 3-NT modification of this protein resulted in loss of its enzymatic activity. CONCLUSIONS There is increased nitrosative stress in CSF of HIV-infected patients with active dementia and in patients with a history of IV drug use, measurement of which may serve as a surrogate marker for these patients. Nitrosative stress may also have important functional consequences and may impact the pathogenesis of HIV-associated neurocognitive disorders.
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Molecular programming of endothelin-1 in HIV-infected brain: role of Tat in up-regulation of ET-1 and its inhibition by statins. FASEB J 2006; 21:777-89. [PMID: 17197385 PMCID: PMC4179467 DOI: 10.1096/fj.06-7054com] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Human Immune Deficiency Virus-1 (HIV-1) infection can induce severe and debilitating neurological problems, including behavioral abnormalities, motor dysfunction, and dementia. HIV can persistently infect astrocytes, during which viral accessory proteins are produced that are unaffected by current antiretroviral therapy. The effect of these proteins on astrocyte function remains unknown. Astrocytes are the predominant cells within the brain; thus, disruption of astrocyte function could influence the neuropathogenesis of HIV infection. To explore further these effects, we constitutively expressed HIV-Tat protein in astrocytes. Since the nuclear presence of Tat protein leads to alteration of host gene expression, we further analyzed the effects of Tat on host gene transcripts. Endothelin-1 (ET-1) was a significantly elevated transcript as verified by reverse transcription-polymerase chain reaction (RT-PCR), and it was subsequently released extracellularly in Tat-expressing and HIV-infected astrocytes. ET-1 expression was also prominent in reactive astrocytes and neurons in brain tissues from basal ganglia and frontal lobes of HIV encephalitic patients. HIV-Tat regulated ET-1 at the transcriptional level through NF-kappaB (NF-kappaB)-responsive sites in the ET-1 promoter. Intriguingly, simvastatin (10 microM) down-regulated HIV-Tat-induced ET-1 and also inhibited activation of NF-kappaB in astrocytes. Our findings suggest that ET-1 may be critical in mediating the neuropathogenesis of HIV dementia and that statins may have therapeutic potential in these patients.
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Therapy Insight: CNS manifestations of HIV-associated immune reconstitution inflammatory syndrome. ACTA ACUST UNITED AC 2006; 2:557-65. [PMID: 16990829 DOI: 10.1038/ncpneuro0303] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2006] [Accepted: 08/03/2006] [Indexed: 11/09/2022]
Abstract
The introduction of combination antiretroviral therapy for HIV infection has prolonged the lives of patients with AIDS. It is increasingly being recognized, however, that following initiation of this therapy some patients can develop a paradoxical neurological deterioration, despite dramatic improvements in HIV viral load and CD4+ T-cell counts. This immune reconstitution inflammatory syndrome (IRIS) in the CNS is emerging as an important neurological complication, particularly as antiretroviral therapy is now becoming readily available worldwide. Currently, there are no guidelines for prevention, diagnosis or treatment of the CNS manifestations of IRIS. Even in patients with an acute presentation, the diagnosis can be challenging. Furthermore, it is possible that more-chronic forms of the syndrome exist but remain unrecognized. Here, we review the various clinical presentations of CNS IRIS, and discuss options for their management.
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Case 8: absentminded and "walking like a drunk". MEDGENMED : MEDSCAPE GENERAL MEDICINE 2005; 7:64. [PMID: 16369369 PMCID: PMC1681424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
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Abstract
We conducted a prospective observational study among a cohort of 40 term parturients undergoing spinal anaesthesia for elective Caesarean section, to determine the concentration of beta-trace protein in cerebrospinal fluid (CSF) and serum. Serum and CSF samples, taken at the time of dural puncture, were assayed by nephelometry. The mean serum beta-trace protein concentration was 0.39 mg.l(-1) and the mean CSF concentration was 27.9 mg.l(-1), giving a mean ratio of CSF to serum concentration of 76. This ratio is higher than that published for non-pregnant females and for males because of both a higher mean CSF and a lower mean serum beta-trace protein concentration. The concentration correlated positively with both serum creatinine and gestational age. If these concentrations are used to estimate the normal range, we propose that the nephelometric measurement of beta-trace protein might prove a useful diagnostic test for cerebrospinal fluid-cutaneous fistula in parturients.
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Intranasal vaccination with streptococcal fibronectin binding protein Sfb1 fails to prevent growth and dissemination of Streptococcus pyogenes in a murine skin infection model. Infect Immun 2004; 72:7342-5. [PMID: 15557665 PMCID: PMC529117 DOI: 10.1128/iai.72.12.7342-7345.2004] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Fibronectin binding protein F1 (Sfb1) of Streptococcus pyogenes (group A streptococcus [GAS]) is a well-characterized adhesin that has been shown to induce protection in mice against a lethal intranasal GAS challenge after intranasal immunization with cholera toxin B subunit (CTB) as adjuvant. With a murine skin infection model, we have shown that Sfb1/CTB vaccination neither elicits opsonizing antibodies nor prevents systemic bacterial growth and dissemination to internal organs after a subcutaneous GAS challenge. These results indicate that an Sfb1-based vaccine should be complemented with additional protective antigens in order to be used in areas such as the tropical north of Australia, where the skin is the primary route of entry for invasive streptococcal diseases.
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A Randomized Controlled Trial of 5% Lidocaine Gel for HIV-Associated Distal Symmetric Polyneuropathy. J Acquir Immune Defic Syndr 2004; 37:1584-6. [PMID: 15577414 DOI: 10.1097/00126334-200412150-00010] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To investigate the analgesic efficacy and safety of 5% lidocaine gel in painful HIV-associated distal sensory polyneuropathy (DSP). BACKGROUND Painful DSP, the most common neurologic complication in HIV infection, is difficult to treat. Lidocaine 5% gel was effective in alleviating neuropathic pain in an open-label study of HIV DSP. METHODS In a double-blind, placebo-controlled, crossover, multi-center study, 64 subjects were randomized to receive 5% lidocaine or vehicle gel for 2 weeks (phase A). A washout period of 2 weeks was followed by a crossover to the alternate agent for another 2 weeks (phase B). The primary outcome was difference in average pain scores (Gracely pain scale) between the 2 groups during the second week of each treatment period. Secondary outcomes included differential effect of the first treatment, difference in global pain relief, and pain response by neurotoxin exposure. RESULTS The baseline pain scores of the 2 groups were similar. The average pain scores during the second week of each phase of the lidocaine gel group did not differ from those of the placebo group (phase A: lidocaine 1.09, placebo 1.15; phase B: lidocaine 1.16, placebo 1.10). There also was no difference noted in secondary outcomes. The pain responses of lidocaine gel-treated subjects with current exposure to neurotoxic antiretrovirals (1.18) did not differ compared with those without (1.10) (P = 0.358). There were no significant adverse effects. CONCLUSION Lidocaine 5% gel is a safe but ineffective agent in the treatment of pain in HIV-associated DSP.
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The reliability of skin biopsy with measurement of intraepidermal nerve fiber density. J Neurol Sci 2004; 228:65-9. [PMID: 15607212 DOI: 10.1016/j.jns.2004.09.032] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2004] [Revised: 09/15/2004] [Accepted: 09/15/2004] [Indexed: 12/15/2022]
Abstract
Intraepidermal nerve fiber density (IENFD) is a sensitive measure of small fiber injury, and holds promise as a clinical trial endpoint measure. A total of 48 punch biopsies were obtained from 22 patients. Tissue was sectioned and stained with PGP9.5. The relative intertrial variability (RIV) of IENFD measurements for each section and punch made by two different observers was determined (interobserver variability). Intraobserver variability (same observer measuring twice) was determined for 50% of the sections and punches. Sections from 12 punch biopsies were also stained at a second laboratory. The effect of the number of sections counted and processing site on reproducibility was investigated. A total of 223 sections were analyzed. The mean IENFD was 6.7 fibers/mm. Mean (+/-standard deviation) interobserver variability was 9.6%+/-9.4 for each biopsy site and 10.2%+/-11.9 for individual sections. Mean intraobserver variability was 9.6%+/-8.9 for biopsies, and 8.8%+/-9.0 for sections. There was no significant difference in IENFD for tissue stained at different laboratories. Intraclass correlation coefficients were greater than 0.98 for each comparison. There was no relationship between absolute IENFD and reproducibility. Reproducibility was highest when four sections were counted. IENFD measurement is highly reproducible. At least four sections should be analyzed. Reliability does not vary with severity of disease. These findings suggest IENFD may be a useful endpoint measure in future neuropathy treatment trials.
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Immune responses of a liposome/ISCOM vaccine adjuvant against streptococcal fibronectin binding protein 1 (Sfb1) in mice. Indian J Med Res 2004; 119 Suppl:115-20. [PMID: 15232175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023] Open
Abstract
BACKGROUND & OBJECTIVES The fibronectin binding protein Sfb1 of Streptococcus pyogenes is a well characterised antigen which induces protection against lethal challenge with group A streptococcus (GAS) when adjuvanted with cholera toxin B-subunit (CTB). As an alternative to CTB adjuvanted intranasal immunisations we investigated the immune responses generated in mice using Sfb1 incorporated in to the skin and mucosal adjuvant SAMA4. METHODS Mice (BALB/c) were vaccinated intradermally with 100 microl of either SAMA4 (adjuvant only group) or SAMA4/Sfb1 and were boosted 7 days later. Mice vaccinated with CTB based vaccines were immunised by intranasal inoculation with a mixture containing 30 microg Sfb1 and 10 microg CTB on days 1, 3, 5 and 15. At 14 days after the last booster immunisation the immune response was characterised and mice were challenged with 10(8) CFU of S. pyogenes. RESULTS Mice vaccinated with SAMA4/Sfb1 elicited a Sfb1-specific IgG response in the sera that was significantly higher than that seen in control mice and mice immunised with the adjuvant only (P<0.05). No significant differences were seen for specific IgA antibodies in the sera in all groups examined. Compared with non-immunised and adjuvant only immunised controls, mice immunised with the Sfb1/SAMA4 vaccine exhibited a significant increase (P<0.05) in the number of Sfb1 reactive spleen cells in lymphoproliferation assays which were three fold higher than those seen for mice vaccinated with the Sfb1/CTB vaccine. Mice vaccinated with CTB/Sfb1 had the highest level of protection (80%) as where mice vaccinated with SAMA4 and SAMA4/Sfb1 displayed no protection (20% and 40%). INTERPRETATION & CONCLUSION These data suggest that the SAMA4 adjuvant used in this study fails to elicit protective immunity in BALB/c mice when used to adjuvant the known protective antigen Sfb1.
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